This coherently presented and readable book by a multidisciplinary group of academics and community project workers tackles the complex issue of health inequalities. The sources of health inequalities are explored and the book examines how they can be understood at a profound sociological, economic and policy level. More importantly, however, the contributors argue that the now customary government approach towards improving health in deprived populations by advising individuals to live healthier lifestyles is simply not enough. Action to promote public health does of course need to come from the government as well as individuals, but, argue the contributors, interventions can only truly succeed if they engage the community in the broadest sense, from policy development downwards. Public service agencies, academic institutions and communities must work as partners to successfully tackle the effects on the health of a community resulting from the ‘wicked issues’ of crime, poor housing, low educational attainment and chronic illness.
The book reports the experience of planning and implementing such partnerships by the five-year Sustainable Health Action Research Programme (SHARP) in Wales. It critically examines the learning from and experience of SHARP in relation to current literature on health inequalities policy and suggests that action research can be used as a tool to explore and tackle complex policy development and implementation issues.
The early chapters set SHARP in context, giving convincing evidence of the increase in health inequalities across the UK, looking in particular at Wales, and suggesting that recent approaches to understanding and explaining health inequalities are more local than in the past. The book argues not only that there should be policy directly aimed at reducing health inequalities, but also that this policy should be decided and implemented locally. It is this looking at ‘what works in the context of what matters’ that can really influence profound and lasting change.
Health inequalities’ policy and how it is made at a political, economic and sociological level is explored and the book argues that evidence-based policy making is insufficient for true ‘policy learning’. Further legitimacy and lasting success can only be provided by local specification and ownership.
The genesis of the SHARP project and how it differs from previous Welsh policy initiatives is outlined and the funded individual projects discussed. The projects, from ‘barefoot’ health workers – recruited from within the minority ethnic community to find culturally and socially appropriate ways of addressing local priorities – to a project for girls and young women in Wrexham, share the same approach: using action research as a tool to not only explore the determinants of health at a local level but to actually bring about change and break the poverty and health inequality continuum in Wales.
The book argues that these local initiatives have led to the development of general concepts and theory about local, community-led policy – ‘what works for whom and at what cost’ – and that these concepts are transferable to a range of communities. Sustained community action and targeted, local partnerships are central in successfully addressing health inequalities at a lasting, community level.
Particular attention is paid to the unique context of devolved government structures and how these are able to support – and occasionally undermine – the many ‘bottom-up’ community solutions to health inequalities described.
The book ends by arguing that we need to look again at how we, as health care policy makers, managers, commissioners, providers, practitioners and academics understand local health care needs and how we tackle public health improvement at a community level.
